RESTORING CARE TO HEALTH CAREFor-profit health care is essentially an oxymoron. The moment care
is rendered for profit it is emptied of genuine caring. The moral contradiction is
beyond repair.
by Bernard Lown

It is no surprise to say that a crisis in health care has been brewing for many
years. What is surprising is how quickly the meltdown has occurred. Much of the reason
lies in the extraordinary control corporations now have in the system.

Patient dissatisfactions is at an all-time high. Health care is not a coherent
system, but a hodgepodge of corporate fiefdoms whose central aim is to maximize profit
for the benefit of investors. To achieve this objective, time-honored clinical decision
making by doctors is being curtailed.

Arbitrary regulations, supervised by a burgeoning bureaucracy for technocrats,
have now invaded every precinct of clinical judgement, whether the question involves
a drug prescription, the need for a specialist, the propriety of an emergency room
visit, or the advisability of hospitalization. Far worse than de-professionalizing
doctors, the current system of managed care is depersonalizing patients.

The industrialization of medicine requires two elements: the standardization of
the product and the interchangeability of its parts. It must be said that this process
preceded Wall Street's takeover of health care. It relates also to the long-standing
marriage of medicine to reductionist science and to evermore sophisticated technology.

In the modern medical paradigm, each patient is a statistic similar to any other
patient with the same illness. Science, in accounting for endlessly diverse biological
phenomena, ignores individual uniqueness in order to abstract the underlying operating
mechanisms.

What modern medicine proclaims as decisive are the biologic commonalities, while
individual differences are given short shrift. If all patients have similar and interchangeable
parts (organ- transplant programs sanction such a simplistic notion), the field is
rendered ripe for corporate control.

How did we get to this point?

The crisis began in the very heartland of medicine. Doctors were seduced by financial
incentives.

At first, unquestioning third-party payers provided an open till. Care was fragmented
among super-specialists, with multiplication of mindless procedures, encouragement
of uncalled-for office visits, and exposure of patients to a glut of unnecessary
surgical interventions. Each test or procedure was converted into a profit center.

Yet, while America was spending far more for health care than any other industrialized
country, over a sixth of the population was denied even rudimentary health care.

Someone was needed to control and manage doctors. The logic presented to the public
was that only competitive, investor-owned health maintenance organizations (HMOs)
- working to generate profit by cutting costs - possessed the financial discipline
to stem inflation of health-care costs. Implicit in this corporate logic was that
sickness could be regarded as a commodity, and that a patient can behave as a sovereign
and knowledgeable consumer of health- care services. Neither assumption is correct.

Consequently, HMOs amplified and aggravated the many inhumanities that prevailed
in the fee-for-service system. There are many highly skilled and caring doctors trying
to practice humane medicine, but it is becoming extraordinarily difficult to do so.
Many doctors are losing heart.

In market-driven medicine, the primacy of the patient yields to the perverse accountability
of investors, bureaucrats, insurers, and employers. For-profit health care demands
that the doctor perform as gatekeeper to ration or deny care. In these circumstances
the patient-doctor relationship is undermined by suspicion that any advice is determined
by the corporate bottom line.

For-profit health care is essentially an oxymoron. The moment care is rendered
for profit it is emptied of genuine caring. This moral contradiction is beyond repair.

The elusive properties of mind and spirit that account for each person's uniqueness
find scant sympathy in the current state religion that worships business efficiency.
Nor do these properties enter the scientific equation.

Patients will not acquiesce to the ultimate alienation of being reduced to standardized
objects. No one will accept for long being merely identified by their illness, or
seen as nothing but an assemblage of broken down biologic parts.

Patients crave a partnership with physicians who are as sensitive to their aching
souls as to their malfunctioning anatomy. They yearn not for a tautly drafted business
contract, but for a covenant of trust between equals earned by the doctor while exercising
the art of caring.

A few years ago, shortly before his death, the essayist Anatole Broyard wrote:

"I wouldn't demand a lot of my doctor's time. I just wish he would brood
on my situation for perhaps five minutes, that he would give me his whole mind just
once, be bonded with me for a brief space, survey my soul as well as my flesh...
Without some such recognition, I am nothing but my illness."

Bernard Lown is professor emeritus of cardiology at the Harvard School of Public
Health and chairman of the Lown Cardiovascular Research Foundation in Brookline,
Mass. He is also the co- recipient of the 1985 Nobel Peace Prize, which he accepted
on behalf of the International Physicians for the Prevention of Nuclear War.